Nokea
A nurse is attending a social event when another guest coughs weakly once, grasps his throat, and cannot talk. Which of the following actions should the nurse take?
- A. Perform the Heimlich maneuver.
- B. Slap the client on the back several times.
- C. Assist the client to the floor and begin mouth-to-mouth resuscitation.
- D. Observe the client before taking further action.
Correct Answer: A
Rationale: The correct answer is A: Perform the Heimlich maneuver. This action is appropriate for a choking individual who is unable to speak, cough weakly, and grasp their throat, indicating a partial airway obstruction. The Heimlich maneuver is designed to dislodge the obstruction by applying abdominal thrusts. This is the most effective intervention in this scenario to clear the airway and restore breathing. Slapping the client on the back (B) may not effectively remove the obstruction. Mouth-to-mouth resuscitation (C) is not indicated for a conscious choking person. Observing the client (D) without taking immediate action can lead to a worsening situation.
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A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)
- A. Plan a plan of care for a client when postoperative from an appendectomy
- B. Provide discharge instructions to a confused client’s spouse
- C. Administer a tap-water enema to a client who is preoperative
- D. Clean vital signs from a client who is 6 hours postoperative
- E. Catheterize a client who has not voided in 8 hours
Correct Answer: C,D,E
Rationale: The correct tasks to delegate to the LPN are C, D, and E. For choice C, administering a tap-water enema to a preoperative client falls within the LPN's scope of practice as it involves a routine procedure that does not require advanced assessment or critical thinking skills. Choice D, cleaning vital signs from a client who is 6 hours postoperative, is a task that can be safely delegated to the LPN as it involves routine monitoring that does not require RN-level judgment. Choice E, catheterizing a client who has not voided in 8 hours, is a task that the LPN can perform as it is a straightforward procedure that the LPN would have been trained to do. Choices A and B involve more complex decision-making and education that are typically within the RN's scope of practice.
A public health nurse is teaching a group of nurses about smallpox. Which of the following statements by one of the nurses indicates understanding of the teaching?
- A. Unlike chickenpox, the vesicles of smallpox are more abundant on the face.
- B. Smallpox lesions appear in various stages of healing.
- C. Vaccination against smallpox provides lifelong immunity.
- D. There are rare, occasional occurrences of smallpox.
Correct Answer: A
Rationale: The correct answer is A because smallpox vesicles are more abundant on the face compared to chickenpox. This is a key characteristic of smallpox that differentiates it from chickenpox. Option B is incorrect because smallpox lesions all appear at the same stage. Option C is incorrect as smallpox vaccination does not provide lifelong immunity. Option D is incorrect as smallpox has been eradicated, so occurrences are not rare but non-existent.
A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Dried fruits
- B. Dried peas
- C. Eggs
- D. Pasta
Correct Answer: C
Rationale: The correct answer is C: Eggs. Eggs are a good source of protein, which is important for clients with a colostomy to promote healing and overall health. They are easily digestible and less likely to cause issues like blockages or gas. Dried fruits (choice A) and dried peas (choice B) can be high in fiber and may lead to digestive problems for colostomy clients. Pasta (choice D) can also be difficult to digest and may cause discomfort. Eggs are a versatile and nutritious option that can be beneficial for clients with a colostomy.
A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?
- A. Administer 50,000 units of heparin by IV bolus every 12 hours.
- B. Have vitamin K available on the nursing unit.
- C. Use tubing specific for heparin sodium when administering the infusion.
- D. Check the activated partial thromboplastin time (aPTT) every 6 hours.
Correct Answer: D
Rationale: The correct answer is D: Check the activated partial thromboplastin time (aPTT) every 6 hours. This is crucial to monitor the therapeutic effect of heparin, ensuring the client's blood does not become too thin or too thick. Regular aPTT monitoring helps adjust the heparin infusion rate to maintain the desired anticoagulant effect.
Explanation of why other choices are incorrect:
A: Administering a large dose of heparin by IV bolus is dangerous and can lead to bleeding complications. Incorrect.
B: Having vitamin K available is not specifically related to managing heparin therapy. Incorrect.
C: Using tubing specific for heparin is important but is not the priority action in this scenario. Incorrect.
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
- A. Promote oral hygiene.
- B. Ensure adequate nutrition.
- C. Prevent aspiration.
- D. Relieve the client’s pain.
Correct Answer: C
Rationale: The correct answer is C: Prevent aspiration. This is the priority because with intermaxillary fixation, the client's ability to swallow and protect their airway is compromised. Aspiration can lead to serious complications such as pneumonia. Promoting oral hygiene (A) can be important but not the priority. Ensuring adequate nutrition (B) is important but can be addressed once the risk of aspiration has been minimized. Relieving pain (D) is also important but not the priority over preventing aspiration in this case.